Treating Severe Pneumonia in Children Can Be Done Safely and
Effectively at Home

LONDON, Jan. 3, 2008--Home treatment of severe
pneumonia in children with oral antibiotics is as safe and
effective as treatment in hospital, according to an Article in this
week’s issue of The Lancet. In light of these findings, WHO
recommendations on the treatment of severe pneumonia need to be
revised, say the authors.

Pneumonia is responsible for the deaths of more
than 2 million children under the age of 5 years every
year—almost four a minute. WHO guidelines for the case
management of acute lower respiratory tract infections recommend
that children with fast breathing (non-severe pneumonia) be treated
at home with oral antibiotics, and those with lower chest indrawing
(severe pneumonia) and general danger signs (very severe disease)
be referred to hospital and treated with parenteral antibiotics
(benzylpenicilllin or ampicillin). However, in developing areas
many children with severe pneumonia referred to hospitals never
reach them for reasons such as poor transportation, cost, distance,
and lack of childcare at home. This makes the current guidelines
ineffective in practice. Safe community-based treatment
alternatives would substantially increase the number of children
receiving effective care, prevent many deaths, decrease the
potential hazards of in-hospital treatment, and reduce costs.

Dr Donald Thea (Boston University School of
Public Health, Boston, USA) and colleagues studied 2037 children
aged 3–59 months at seven study sites in Pakistan to
determine whether home-based treatment of severe pneumonia with
oral antibiotics is as safe and as effective as inpatient
parenteral treatment. About half the children were randomly
assigned to receive oral amoxicillin syrup and were sent home, and
the other half to receive intravenous ampicillin for 48h as an
inpatient.

The researchers found that there were 87
treatment failures in the hospitalised group and 77 in the
home-based group (8·6% vs 7·5%) by day 6. Five
children died within 14 days of enrolment, one in the home-based
group and four in the hospitalised group. In each case, treatment
failure was declared before death and the antibiotic was changed.
The authors noted that none of the deaths were considered to be
associated with study treatment, and that there were no serious
adverse events reported in the trial.

The authors say: "Home treatment with high-dose
oral amoxicillin is equivalent to currently recommended
hospitalisation and parenteral ampicillin for treatment of severe
pneumonia without underlying complications, suggesting that WHO
recommendations for treatment of severe pneumonia need to be
revised."

The authors conclude: "Because the agents that
cause pneumonia in Pakistani children do not differ from those in
most other developing countries, our findings have important
public-health policy and programmatic implications, particularly
for Integrated Management of Childhood Illness (IMCI)
guidelines...Ambulatory management of severe pneumonia in children
has the potential to improve access to care and inequity while
reducing costs and mortality from pneumonia."

In an accompanying Comment, Dr Shams El Arifeen
(International Centre for Diarrhoeal Disease Research, Bangladesh,
Dhaka, Bangladesh) and Dr Abdullah Baqui (John Hopkins Bloomberg
School of Public Health, Baltimore, USA) say: "[The] finding that
oral treatment outside a hospital is safe and efficacious is a
milestone...[and] should change the management of severe pneumonia
in children in developing countries." They continue: "We would
benefit from considering severe pneumonia without danger signs,
complications, or other severe conditions as a distinct category
that could be safely and effectively treated with oral antibiotics
outside hospitals, with the possible exceptions of patients less
then 6 months of age, those with very fast breathing, or those
moderately underweight."

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